2024 MIPS Measures Relevant to Ophthalmology

  1. Quality - 30% of total score:  Report 6 measures, including one Outcome or other High Priority measure for 12 months on at least 70% of eligible encounters to receive a score against 2023 National Benchmarks. Suggestions for your specialty include, but are not limited to, the following:   
    ID:
    012
    NQF:
    0086
    eMeasure ID:
    CMS143v12
    High Priority:
    No

    2024 MIPS Measure #012: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

    Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more visits within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Ophthalmology
    ID:
    019
    NQF:
    eMeasure ID:
    CMS142v12
    High Priority:
    Yes

    2024 MIPS Measure #019: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

    Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once during the performance period.

    Measure Type
    • Process
    Specifications
    Specialty
    • Ophthalmology
    ID:
    117
    NQF:
    0055
    eMeasure ID:
    CMS131v12
    High Priority:
    No

    2024 MIPS Measure #117: Diabetes: Eye Exam

    Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam during the measurement period or diabetics with no diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam during the measurement period or in the 12 months prior to the measurement period.

    Measure Type
    • Process
    Specifications
    Specialty
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Ophthalmology
    ID:
    130
    NQF:
    eMeasure ID:
    CMS68v13
    High Priority:
    Yes

    2024 MIPS Measure #130: Documentation of Current Medications in the Medical Record

    Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Audiology
    • Cardiology
    • Certified Nurse Midwife
    • Clinical Social Work
    • Dermatology
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Geriatrics
    • Hospitalists
    • Infectious Disease
    • Internal Medicine
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Neurosurgery
    • Nutrition/Dietician
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Plastic Surgery
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Speech/Language Pathology
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:
    141
    NQF:
    0563
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care

    Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 20% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 20% from the pre-intervention level, a plan of care was documented within the 12 month performance period.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    191
    NQF:
    0565
    eMeasure ID:
    CMS133v12
    High Priority:
    Yes

    2024 MIPS Measure #191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

    Percentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    226
    NQF:
    0028
    eMeasure ID:
    CMS138v12
    High Priority:
    No

    2024 MIPS Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

    Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Audiology
    • Cardiology
    • Certified Nurse Midwife
    • Clinical Social Work
    • Dermatology
    • Endocrinology
    • Gastroenterology
    • General Surgery
    • Infectious Disease
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Neurosurgery
    • Nutrition/Dietician
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Pediatrics
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Plastic Surgery
    • Podiatry
    • Pulmonology
    • Radiation Oncology
    • Rheumatology
    • Speech/Language Pathology
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:
    238
    NQF:
    0022
    eMeasure ID:
    CMS156v12
    High Priority:
    Yes

    2024 MIPS Measure #238: Use of High-Risk Medications in Older Adults

    Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Oncology/Hematology
    • Ophthalmology
    • Otolaryngology
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    • Urology
    ID:
    303
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #303: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery

    Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    304
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #304: Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

    Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    374
    NQF:
    eMeasure ID:
    CMS50v12
    High Priority:
    Yes

    2024 MIPS Measure #374: Closing the Referral Loop: Receipt of Specialist Report

    Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Interventional Radiology
    • Neurology
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:
    384
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #384: Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery

    Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    385
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery

    Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    389
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #389: Cataract Surgery: Difference Between Planned and Final Refraction

    Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Ophthalmology
    ID:
    487
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #487: Screening for Social Drivers of Health

    Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Audiology
    • Cardiology
    • Certified Nurse Midwife
    • Chiropractic Medicine
    • Clinical Social Work
    • Dermatology
    • Emergency Medicine
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Geriatrics
    • Infectious Disease
    • Internal Medicine
    • Interventional Radiology
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Neurosurgery
    • Nutrition/Dietician
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Pediatrics
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Plastic Surgery
    • Podiatry
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    • Speech/Language Pathology
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:
    498
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2024 MIPS Measure #498: Connection to Community Service Provider

    Percent of patients 18 years or older who screen positive for one or more of the following health-related social needs (HRSNs): food insecurity, housing instability, transportation needs, utility help needs, or interpersonal safety; and had contact with a Community Service Provider (CSP) for at least one of their HRSNs within 60 days after screening.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Audiology
    • Cardiology
    • Certified Nurse Midwife
    • Chiropractic Medicine
    • Clinical Social Work
    • Dermatology
    • Emergency Medicine
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Geriatrics
    • Infectious Disease
    • Internal Medicine
    • Interventional Radiology
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Neurosurgery
    • Nutrition/Dietician
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Pediatrics
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Plastic Surgery
    • Podiatry
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    • Speech/Language Pathology
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:
    499
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #499: Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy

    Percentage of patients who had an intravitreal or periocular corticosteroid injection (e.g., triamcinolone, preservativefree triamcinolone, dexamethasone, dexamethasone intravitreal implant, or fluocinolone intravitreal implant) who, within seven (7) weeks following the date of injection, are screened for elevated intraocular pressure (IOP) with tonometry with documented IOP ≤ 25 mm Hg for injected eye OR if the IOP was > 25 mm Hg, a plan of care was documented.

    Measure Type
    • Process
    Specifications
    Specialty
    • Ophthalmology
    ID:
    500
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #500: Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up

    Percentage of patients with a diagnosis of acute posterior vitreous detachment (PVD) in either eye who were appropriately evaluated during the initial exam and were re-evaluated no later than 8 weeks.

    Measure Type
    • Process
    Specifications
    Specialty
    • Ophthalmology
    ID:
    501
    NQF:
    eMeasure ID:
    High Priority:
    No

    2024 MIPS Measure #501: Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up

    Percentage of patients with a diagnosis of acute posterior vitreous detachment (PVD) and acute vitreous hemorrhage in either eye who were appropriately evaluated during the initial exam and were re-evaluated no later than 2 weeks.

    Measure Type
    • Process
    Specifications
    Specialty
    • Ophthalmology
     
  2. PI: Promoting Interoperability - 25% of total score: For a minimum of 90 days, report all required measures. EHR technology certified to the 2015 Cures Update must be in place by October 3, 2023. There are exclusions available for most of the required measures. Please check your QPP Participation Status to see if you are automatically exempt from PI. If you are exempt, the 25% will be re-weighted to the Quality performance category making it 55% of your score.
  3. IA: Improvement Activities - 15% of total score:  Attest that you completed up to 2 high-weighted activities or 4 medium-weighted activities for a minimum of 90 days. Groups with 15 or fewer participants or if you are in a rural or health professional shortage area,  attest that you completed 1 high-weighted or 2 medium-weighted activities for a minimum of 90 days. A group can attest to an activity when at least 50% of the clinicians in the group perform the same activity during any continuous 90-day period (or as specified in the activity description) in the same performance year.  The following are suggestions for your specialty:

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